This is the fourth article in a series of five articles focused on the most pressing issues in patient safety and infection control, published during International Infection Control Week. The series is sponsored by X-STATIC®. Access the first article on hand hygiene here. Access the second article on safe injection practices here. Access the third article on OR collaboration here. This article was written by Peggy Prinz Luebbert, MS, MT (ASCP), CIC, CHSP, founder of Healthcare Interventions, Inc.
In the fight to prevent infections in the healthcare setting, we are taking a closer look at policies and procedures associated with the patient's environment. It is common to hear the phrase, "Infectibility is directly related to dosage" when an infection preventionist refers to the risk of transmission of microorganisms in the environment. This means that if we can decrease the bioburden of microorganisms in the environment, the risk of transmission to patients and healthcare staff would logically also decrease.
Studies have shown that soft surfaces — lab coats, scrubs, cubicle curtains — in the healthcare environment are contaminated, that cross contamination does occur and that laundering practices alone are not effective, as recontamination happens quickly. Given this evidence, it is time to take a look at including soft surfaces in our infection prevention bundle for environmental disinfection. An effective infection prevention program can decrease the overall risk using these six key steps:
1. Good hand hygiene practices. Under CDC's Standard Precautions, good hand hygiene should be performed after contact with any body fluids or contaminated surfaces. To limit further contamination of the environment, this should occur before any later contact with the patient, clean hard surfaces (bed rails, catheters) or soft surface fabrics such as personal uniforms, patient linen and privacy curtains.
Education of healthcare workers at orientation and again on a regular basis should remind them of the importance of preventing cross contamination to clean surfaces from contaminated hands.
2. Effective contact isolation practices. When dealing with significant multi-drug resistant organisms or uncontrolled body fluid contamination of the environment, patients should be placed into CDC's Contact Precautions.
The proper signage and practices will help to minimize environmental contamination and to make the healthcare worker more aware of the additional risk of exposure and transmission.
3. Proper laundering of uniforms. The potential for survival and spread of pathogens transferred to and from humans and clothing on linens is shown by various laboratory studies. These studies show that survival does occur but varies considerably between different microbial strains — and depends on factors such as temperature, relative humidity, type of fabric and inoculum size.
Since we know that these organisms can live and proliferate on fabrics, we depend upon the healthcare workers to effectively wash their uniforms to remove the germs. Our best practices recommend that these fabrics be washed after each day's wear. According to the Association of periOperative Registered Nurses, surgical attire should be laundered in a healthcare accredited laundry facility. These facilities are preferred because they follow standardized industry standards for proper disinfection of fabrics. The Healthcare Laundry Accreditation Council offers voluntary accreditation for those laundry facilities that process reusable health care soft surface textiles that incorporate OSHA and CDC guidelines.
Healthcare workers, outside of the operating room setting, tend to launder their uniforms at home. However, uniforms should be laundered in a manner which not only renders them aesthetically clean, but also hygienically clean (i.e. free from pathogens). Laundry products need to be clearly labeled so consumers can understand whether, and under what laundering conditions, their laundry products can be expected to produce fabrics which are hygienically as well as visibly clean. This is achieved by a combination of heat, rinsing, detergent and chemical oxidative action.
There is also evidence to show that transfer of pathogens can occur between contaminated and clean laundry during the washing cycle. This concern may be related to the ambient water temperatures used today as well as the disappearing practice of ironing clothes. Clothes dryers have added a slight margin of safety depending upon the temperature and the length of the drying time. Still, further action needs to be taken once uniforms are put into use as recontamination happens quickly and persists during the course of a shift.
4. Use of antimicrobial fabrics. Studies have shown that fabrics in healthcare settings quickly become contaminated with microorganisms while in use. Adding antimicrobial properties to these fabrics can potentially limit bioburden and cross contamination. A variety of technologies have been developed in the past decade to accomplish this. To be approved under EPAs "non-public health" regulations, these antimicrobial fabric manufacturers have to prove to do the following:
• decrease microbial growth on the fabrics
• reduce degradation of the fabric over time
• be safe for people and the environment
Examples of some of the antimicrobial technologies available on soft surface textiles include:
o Silver products. The antimicrobial properties of silver have been known to cultures for many centuries. Silver continuously combats microbes in three ways: disrupts cell metabolism; inhibits respiration; and inhibits cell division (reproduction). There are a variety of technologies available today that incorporate silver into fabrics.
o Metallic silver is permanently bonded to the surface of nylon fibers, which are then woven directly into a fabric (a lab coat or privacy curtain). The antimicrobial properties are inherent in the fabric and active for the life of the product. Within one hour of contact to the fabric, 99.9 percent of bacterial and fungal organisms will be killed.
o Silver zeolite is a crystal based powder that is added as a coating, resin or additive to fibers. Silver is embedded within micron-sized carriers called zeolite and then encapsulated in the polyurethane surface of fabrics.
o Silver nano technology releases antimicrobial silver ions in steady rates from the fabrics.
o Silane-based quaternary ammonium chloride antimicrobial. This technology uses the coupling agent silane to attach the quaternary ammonium chloride to fibers.
o Chemical combinations. Multiple technologies using as many as 20 different chemicals in a
variety of arrangements have been added to fabrics as antimicrobials.
o Copper products. Copper has historically been shown to be antimicrobial in nature. Currently
found in many home as well as medical products.
5. Hard surface disinfection. Environmental contamination of hard surfaces can occur after contact with body fluids or other contaminated surfaces and skin. To minimize cross contamination to hands and soft surface fabrics, these surfaces should be disinfected properly as soon as possible after they become unclean. For example, a healthcare worker reaching across a patient's bed can come in contact with a dirty bed rail with their uniform and is at risk of contaminating her hands and other inanimate surfaces later during her work shift or at home. Use of a proper EPA registered healthcare disinfectant is essential.
6. Proper use of PPE. As with contaminated hands, contaminated gloved hands should not touch clean surfaces. For example, staff should be reminded to not take items in and out of their uniform pocket with contaminated gloved hands (i.e. tape, scissors, patient lists). Contaminated PPEs such as gloves, gowns and facial protection should be doffed safely as well as to not contaminate the healthcare worker's uniform or scrubs or nearby hard surfaces.
Conclusion
In the effort to target zero healthcare associated infections, it's important to address all the potential areas of environmental contamination. Any gap in practice leaves the chain of infection unbroken and soft surface fabrics have largely been a missing piece in infection prevention protocols. What's promising is the increased amount of research on this topic in the last decade that will help to create best practices. However, the industry needs to invest time and money in completing the necessary
clinical studies, evaluating the potential benefits associated with infection prevention textiles as a continuous solution and creating guidelines and standard protocols for soft surface bacterial management.
Learn more about Healthcare Interventions, Inc.
